Failure to Implement Fall Interventions and Complete Post-Fall Neuro Assessments
Penalty
Summary
The deficiency involves the facility’s failure to implement adequate fall-prevention interventions and to complete required neurological assessments after falls for one resident. The resident had moderate cognitive impairment, required partial to moderate assistance with multiple ADLs, and had diagnoses including atrial fibrillation, cirrhosis, arthritis, and a history of repeated falls. The care plan identified the resident as at risk for falls related to impaired cognition and recent falls, with an intervention that the resident wear gripper socks in bed. Progress notes documented that on one occasion the resident was found on the floor between the bed and the wall, gripping the curtains, with the bed in the lowest position and grippy socks on, and the resident was only able to answer simple yes/no questions and could not explain what he had attempted to do. On another occasion, the resident was found on the floor by his dresser, leaning on his left arm, reporting left arm pain and having a 4 x 3 cm skin tear near the left elbow, and it required three staff with a gait belt to transfer him to a wheelchair. The facility also failed to complete neurological assessments as required by its fall occurrence policy following these falls. After the first fall, the Neurological Evaluation Flow Sheet initiated that evening lacked completed assessments at several scheduled times, with multiple entries indicating the resident was sleeping and missing vital signs and other required data at specific hours. Some entries documented the resident as sleeping but still included vital signs and pupil assessments, creating inconsistencies. Following a later fall in which the resident was found sitting on the floor with his wheelchair behind him, another neurological flow sheet was initiated, but it lacked completed assessments at additional scheduled times, again marked as sleeping. The facility’s policy required neurological evaluations with vital signs initially, then every 30 minutes times four, every hour times four, and then every eight hours times nine (for a total of 72 hours), with documentation and monitoring for 72 hours post-fall, which was not fully carried out for this resident.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.